Diet and Non-Communicable Diseases (NCDs): latest evidence

Fumiaki Imamura, MS, PhD fumiaki.Imamura@mrc-epid.cam.ac.uk

23 Nov 2016, London

↑↑↑ publications in our field ↑↑↑

• N journals=436

• N publications:

Pubmed

0

30000

60000

90000

1960 1970 1980 1990 2000 2010

Global Burden of Disease

0

5

10

15

20

25

Communicable Nutr Deficit CVD and Cancer

1990 2010

Million Deaths

Lozano et al., Lancet 2012; 380: 2095–128

Global Burdens of Diseases

GBD 2013 Risk Factors Collaborators, Lancet, 2015

% Loss of Life Years

0 2.5 5.0 7.5 10.0

Diet

Smoking Nutr Deficit

Alcohol

Physical activity

Obesity

Hypertension

Studies of Diet and Health

D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S

Overall Diet

Nutrients

Foods

e.g.

• Saturated fat

• Meat/oils

• High-fat diet

↓ SFA ↓ Heart disease ???

in arteries by Gulliver G,

Med Chir Trans, 1843

The Elements of Physiology Blumenbach, 1828

Keys A., 1980

Saturated fatty acids (SFA) consumption raises blood cholesterol.

Publications N trials

Mensink, Arteriosc Thromb, 1993 27

Clarke, BMJ, 1997 395

Mensink, Am J Clin Nutr, 2003 60

SFA→PUFA

SFA→MUFA

↓ Cholesterol

Decrease in total cholesterol (mmol/L)

Women’s Health Initiative (WHI)

48835, randomised

19541 Low fat

29294 Usual

0 2 4 6 8

Year

0.06

0.05

0.04

0.03

0.02

0.01

0

Heart disease %

Howard et al., JAMA, 2006

Control

Intervention

Dietary intakes in WHI

Howard et al., JAMA, 2006

0

15

30

45

Baseline Year 6

0

15

30

45

Baseline Year 6

Control group “Low fat” % of

energy

Total fat

SFA

Total fat*

SFA *

*P<0.05

Dietary intakes in WHI

Howard et al., JAMA, 2006

0

15

30

45

Baseline Year 6

0

15

30

45

Baseline Year 6

Control group “Low fat” % of energy

or gram/day Nuts Carb.

PUFA

Nuts *

Carb. *

PUFA*

*P<0.05

↓ SFAs,

High in what?

Energy from butter

oil (PUFA)

sugars

Is butter really back? Clarifying the facts on fat Harvard School of Public Health

SFA intake and heart disease

Chowdhury et al,

Ann Intern Med. 2014

Summary evidence on ↓ SFA intake and heart disease

Meta-analysis N Relative Risk

(95% CI) Effect

On CHD

Observational

Jacobsen, 2009 11 0.87 (0.77, 0.97)

Mente, 2009 11 1.06 (0.96, 1.15)

Siri-Tarino, 2010 16 1.07 (0.96, 1.19)

Chowdhury, 2014 20 1.03 (0.98, 1.07)

Farvid, 2014 10 0.90 (0.85, 0.94)

de Souza, 2015 12 1.06 (0.95, 1.17)

Trials

Skeaff, 2009 8 0.83 (0.69, 1.00)

Mozaffarian, 2010 7 0.81 (0.70, 0.95)

Hooper, 2000/01/12/15 23 0.93 (0.84, 1.02)

Ramsden, 2010/13/15 7 0.98 (0.82, 1.19)

Schwingshackl, 2014 12 0.76 (0.54, 1.09)

Horcombe, 2015 7 0.99 (0.78, 1.25)

“Summary evidence” on ↓ SFA intake and heart disease

Meta-analysis N Relative Risk

(95% CI) Effect

On CHD

Observational

Jacobsen, 2009 11 0.87 (0.77, 0.97)

Mente, 2009 11 1.06 (0.96, 1.15)

Siri-Tarino, 2010 16 1.07 (0.96, 1.19)

Chowdhury, 2014 20 1.03 (0.98, 1.07)

Farvid, 2014 10 0.90 (0.85, 0.94)

de Souza, 2015 12 1.06 (0.95, 1.17)

Trials

Skeaff, 2009 8 0.83 (0.69, 1.00)

Mozaffarian, 2010 7 0.81 (0.70, 0.95)

Hooper, 2000/01/12/15 23 0.93 (0.84, 1.02)

Ramsden, 2010/13/15 7 0.98 (0.82, 1.19)

Schwingshackl, 2014 12 0.76 (0.54, 1.09)

Horcombe, 2015 7 0.99 (0.78, 1.25)

↓ SFAs,

High in what?

Energy from butter

olive oil

sugars

Is butter really back? Clarifying the facts on fat Harvard School of Public Health

Trans-fat-rich margarine

“Summary evidence” on ↓ SFA intake and heart disease

Meta-analysis N Relative Risk

(95% CI) Effect

On CHD

Observational

Jacobsen, 2009 11 0.87 (0.77, 0.97)

Mente, 2009 11 1.06 (0.96, 1.15)

Siri-Tarino, 2010 16 1.07 (0.96, 1.19)

Chowdhury, 2014 20 1.03 (0.98, 1.07)

Farvid, 2014 10 0.90 (0.85, 0.94)

de Souza, 2015 12 1.06 (0.95, 1.17)

Trials

Skeaff, 2009 8 0.83 (0.69, 1.00)

Mozaffarian, 2010 7 0.81 (0.70, 0.95)

Hooper, 2000/01/12/15 23 0.93 (0.84, 1.02)

Ramsden, 2010/13/15 7 0.98 (0.82, 1.19)

Schwingshackl, 2014 12 0.76 (0.54, 1.09)

Horcombe, 2015 7 0.99 (0.78, 1.25)

“Summary evidence” on ↓ SFA intake and heart disease

Meta-analysis N Relative Risk

(95% CI) Effect

On CHD

Observational

Jacobsen, 2009 11 0.87 (0.77, 0.97)

Mente, 2009 11 1.06 (0.96, 1.15)

Siri-Tarino, 2010 16 1.07 (0.96, 1.19)

Chowdhury, 2014 20 1.03 (0.98, 1.07)

Farvid, 2014 10 0.90 (0.85, 0.94)

de Souza, 2015 12 1.06 (0.95, 1.17)

Trials

Skeaff, 2009 8 0.83 (0.69, 1.00)

Mozaffarian, 2010 7 0.81 (0.70, 0.95)

Hooper, 2000/01/12/15 23 0.93 (0.84, 1.02)

Ramsden, 2010/13/15 7 0.98 (0.82, 1.19)

Schwingshackl, 2014 12 0.76 (0.54, 1.09)

Horcombe, 2015 7 0.99 (0.78, 1.25)

Meta-analysis of SFA intake and heart disease

• If we consider single macronutrients,

we need to consider possible substitution/comparison.

• Mutivariate / ‘network’ meta-analysis in nutritional epidemiology: • Clarke et al., BMJ, 1997

• Johnson et al., JAMA, 2014

• Imamura et al., PLoS Med, 2016

Studies of Diet and Health

D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S

Overall Diet

Nutrients

Foods

e.g.

• Saturated fat

• Meat/oils

• High-fat diet

Sodium and NCDs

D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S

Overall Diet

Nutrients

Foods

e.g.

• Sodium →

Blood pressure

• Cardiovascular diseases (CVD)

High sodium in urine was not related to higher risk of CVD or deaths (n=69,559)

Risk of CVD/deaths

Urinary sodium

Mente et al., Lancet, 2016

Sodium and NCDs

D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S

Overall Diet

Nutrients

Foods

e.g.

• Sodium →

Blood pressure

• Processed meats

• Cardiovascular diseases (CVD)

Smoking and health

Mediterranean Diet

• High “good” fat (Olive oil)

• Vegetables, fruits, fibre, beans, legumes, fish, yogurt, cheese, wine

CHD mortality

Key, Circulation, 1970

Lyon Diet Heart Study 605 CHD patients

↓ Risk= 77%

de Lorgeril et al., Circulation, 1999;99:779-785

Physicians’ advice only

Mediterranean-type diet

PREDIMED Study 7,447 adults at high risk of CHD*

Total CHD

*with diabetes or 3 risk factors for heart diseases Estruch R et al., NEJM, 2013; Appel LJ, Van Horn L., NEJM, 2013

↓ 29% (10-44%)

No effects on body weight (PREDIMED)

Weight, kg

Year

Estruch et al., Lancet Diab Endcrinol, 2016

Is the diet healthy for the UK adults?

The Mediterranean Diet Foundation

23,902 adults in the Norfolk region over 20 years (EPIC Norfolk Study)

±0% –20%

Higher risk Lower risk

–10%

TYN Tong et al., BMC Medicine, 2016

How much of CVD (%) can be preventable by the diet???

27.8

8.5

0

10

20

30

PREDIMED Spain

Norfolk UK

Limitations in the Mediterranean diet (and other patterns)

• Not comprehensive

• No info on beverages • Sugar-sweetened drinks

• Coffee

• Tea

• No info on cooking methods • Fried or grilled fish

• Weak emphasis on subtypes… • Starchy vegetables or not

• Yoghurt, cheese, milk

• Grain products

Studies of Diet and Health

Overall Diet

Nutrients

Foods

• “How efficacious/effective?”

• Generalisable?

• Comprehensive?

Diet cost vs health cost

Greenhouse gas emission

Nordic diet

Emphasis on

• Oily fish

• Rye breads

• Rapeseed oil

• Berries…

Adamsson, J Intern Med, 2011;269:150-159 Uusitupa, J Intern Med, 2013;274:52-66

Poulsen, Am J Clin Nutr, 2014;99:35-45 Mithril, Public Health Nutr, 2013;16:777-785

Kanerva, Br J Nutr, 2013;109:520-528 Kolehmainen, Am J Clin Nutr, 2015;101:228-239

Dietary patterns for nutrient studies

D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S

Overall Diet

Nutrients

Foods

e.g. Sat fat, sodium, …

• Ecological or metabolic studies

Dietary patterns for nutrient studies

D.R. Jacobs Jr, Am J Clin Nutr, 2003;78(suppl):508S–13S

Overall Diet

Nutrients

Foods

• What are the healthy/unhealthy components?

Healthy/Unhealthy diet Why?

Resveratrol

Oleocanthal

Trimethyl-amine oxide (TMAO)

Remarks

• Research on nutrients/foods help understand mechanisms and justify benefits/harm • Be careful about fit to a dietary pattern

• Research on dietary patterns has provided useful evidence • Comprehensive?

• Generalisable?

• Food culture, acceptability, affordabiilty

Healthy British Diet?

SFA intake on the globe.

Micha et al, BMJ. 2014

Coconut oil

Butter

Beef fat

Pork fat (lard)

Soybean oil

Olive oil

Corn oil

Canola oil

Safflower oil

0 20 40 60 80 100

Adapted from Dietary Guidelines for Americans 2010

% of total fat

Monounsaturated (MUFA)

Polyunsaturated (PUFA)

Saturated (SFA)

Saturated fatty acids (SFA) high in solid fat and animal fat

SFAs and health

in arteries

Gulliver G,

Med Chir Trans, 1843

The Elements of Physiology Blumenbach, 1828

Borch, Anal Chem, 1975.

Blood SFA≠dietary SFA Sugars/Alcohol → Blood SFA

High carb.

25

20

15

10

5

0 0 40 80 120 160

Total Fat, g/day

Breast Cancer

per 100,000

Carroll, Cancer Res, 1975;35:3374-3383 Bingham et al., Nat Rev Cancer,2004;4:206

Fat and breast cancer

Total fat, SFAs and breast cancer

±0% +20% –20%

Higher risk Lower risk

Total Fat

SFAs

Multi-countries*

UK

Hunter et al., NEJM, 1996;334:356-61 Key, AJCN, 2011;94:1043-52

*US, Netherlands, Sweden, Canada